FAMILIES UNITED YOUTH RETREAT TROUT LODGE POTOSI, MO JUNE 30-JULY 1, 2018 REGISTRATION FORM

FAMILIES UNITED YOUTH RETREAT
TROUT LODGE POTOSI, MO
JUNE 30-JULY 1, 2018
REGISTRATION FORM
Youth Information
Full Name

First NameMiddle NameLast Name
Birth Date:

MonthDayYear
Date
Sex:
Youth lives with (check all that apply):
Youth Race/Ethnicity
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
T-Shirts Sizes
S
M
L
XL
XXL
XXXL
Deadline June 15, 2018.

PARENT/GUARDIAN INFORMATION

(Answer the questions below for the primary parent/guardian living in the home)
Name

PrefixFirst NameMiddle NameLast Name
Relationship to youth:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Signature:

Clear
Date
EMERGENCY CONTACT (IF DIFFERENT FROM ABOVE)
Name

PrefixFirst NameMiddle NameLast Name
Relationship to youth:
Phone Number

Area CodePhone Number
YesNo
If yes, Important to let us know!

OFFICE USE ONLY
Deposit:	Balance Due:
Online Registration:	Visa/Master Card:	PayPal:
Name on Check:	Check Date:	Check#
Cash/Check / Money Order Amount	Final Payment Received:
Signature: __________________________________ Date: _____________________

Click to edit this text...

IMPORTANT INFORMATION
Physician:
Phone Number

Area CodePhone Number
Address:
Copy of Insurance Card Enclosed or fill in the information:
Insurance Company
Group Number
Other information as needed
Prescription Medication and/or Over the Counter Medication Release: If your child is taking prescription or over the
counter medication while attending camp, the Families United staff must have permission to disperse that
medication. I hereby give the Families United health care staff/counselors permission to administer prescription
medications as directed by the prescribing physician and described on the form to my child while attending camp.
Every effort is made to keep your child healthy and safe, illness and injuries can sometimes occur. Should a medical
emergency occur, you will be notified immediately. If we are unable to reach you and your child needs medical
attention, your child will be transported to the Washington Memorial County Hospital, Potosi, MO and treated by the
physician on duty.
By signing the following authorizations you are giving your consent in advance for medical treatment.

Emergency Treatment Release

I grant permission to have my son/daughter or ward treated, in the event of an illness or injury, at a medical facility.
In the event I cannot be reached, I give permission to the physician selected by the Trout Lodge Camp to secure and
administer proper medical treatment, hospitalize, order injection, anesthesia, or surgery for the participant.
Furthermore, I hereby state that I am aware and accept the risk inherent in the program activity. The undersigned
does herby agree to hold harmless and indemnify the Families United, and the Trout Lodge Camp, their officers,
agents, and employees, from any and all liability, loss, actions, or those of this participant, in the course of the camp.
I agree to reimburse the Families United for any expense that may incur for medical treatment at Washington
Memorial County Hospital, Potosi, MO. The Washington Memorial Cou
Signature:

Clear
Date
Families United Healthy Relationship program is designed to support and equip individuals with the skills and
knowledge necessary to form and sustain a healthy relationship. Participants of the program will NOT be coerced or forced into a relationship or encouraged to remain in an abusive or violent relationship. My signature certifies that I understand participation in the program is totally voluntary. As part of this program, research may be conducted or statistical information may be gathered. Information from this form will be shared with the Program Evaluator only. Participants will never be individually identified in any
statistics or research materials. I grant permission for photographs taken of my youth to be used in advertising and promotional materials.

I grant permission for photographs taken of my youth to be used in advertising and promotional materials.
Youth Signature

Clear
Date
Parent Signature

Clear
Date
Should be Empty:

FAMILIES UNITED YOUTH RETREAT TROUT LODGE POTOSI, MOJUNE 30-JULY 1, 2018REGISTRATION FORM

Youth Information

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACT (IF DIFFERENT FROM ABOVE)

IMPORTANT INFORMATION

FAMILIES UNITED YOUTH RETREAT
TROUT LODGE POTOSI, MO
JUNE 30-JULY 1, 2018
REGISTRATION FORM